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345 Potts Rd •Permiuc�'s 4f M&C DAME COUNTY HEALTH DEPARTMENT Name: e. I4_VInlppr. Environmental Health Section PROPER'T'Y INFORMATION 1'.O ri(✓1 1 O . Boa 848 Diinorect ns m to property: 1 Mucks'ille. NC 27029 Subdivision Nance {boS �> C.�j CL� Phone U:336-751-8760 Section: Lm: ' AUTHORIZATION FOR 'N',\STF;Nb\TF.R Tax 0((icc PIN:M - S\'STEMCON'STRUCTION - AUTHORIZATION NO: 2389 pC n Ru' Name � rJ J115� "NOTE"This Authorization Air Wxstex'aler Svstem Conso-uction MUST 13E ISSUBD by the Da :nvironmenml Health Section prior to issuance of nnv Building Permits.This FomUAulhon,tion Numhershould tx presented m the Um'ie Cnunry'Building InspectionsOffice when applying for Building Per,its. (In compliance with Article 11 of G.S.Chapter 130A.WaMcwaler System..Section.19M Sewage Treatment and Dispmal SvslemN �Yl`/� / C / "'NOTICE­THIS AUTHORIZATION FOR\YAST'ENS\TERCONSTRUCTION �// IS VALID FOR A PERIOD OF FIVE)'EARS. ENVIRON:ijE.S'i'AL"FTFACI'H SPMALLIST DAl :F ISSUEl> RESIDENTIAL SPECIFICATION:BUILDING TYPE ❑S #BEDROOMS L4 -BATHS—?- #OCCUPANTS ,r GARBAGE DISPOSAL:Yesor No COMMERCIAALSSPEE/CrIFlCATION: FACILITYTYPE #PEOPLE_ #PEOPLEISHIFT #SEATS_ INDUSTRIAL WASTE:Yes or No 2•✓ I LOTSIZE ""TYPE WATER SUPPLY WFII DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE �i p SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMPTANK_GAL. TRENCH WIDTH `� ROCK DEPTH ICl~ LINEAR FT. OTHER I >ISC.re111a.� l 1 1/ (� '.'�(( p "/� REQUIRED SITE MODIFICATIONSICONDITIONS: )ASTALL Qry ('MJ 00 ICL-u: /Q� N� 69 Ir..ly I JJ IMPROVEMENT PERMIT LAYOUT 35 h LM»A (((-J7TJ�RtN SI{STt:Yc+- a J 6 4 dll COLI WaTtr� Q = a r ry4�„J � IrLru� '�''\' NLIA� Ek15TIJb '•CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEENBJ0 9:30A.M.ORI:00 1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: IN 'l�- AUTHORUATIONNO. VIQ OPERATION PERMIT BY: / DATE: •-THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE S YST 1 CRIBED ABOVE HAS ?EN INSTALLED IN COMPLIANCE . WITH ARTICLE 1 I OF G.S.CHAPTER 130A,SECTION.1900 SEWAGE TREATMENT AND DISPOSAL SYSTEMS".BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCNDOL03(ReriWl GG .�z�-- .�./_ �-/ / �nJJ ✓"err' 7ot9 to Y; Pemuttees ,� , r ,; ;t `. ,. DAME COUNTY HEALTH DEPARTMENT IN*Name; '�: 1,4•1 1° •- t ' Environmental Health Section PROPERTY INFORMATION '1 " P.O. Box 848 Directions to property: Mocksville, NC 27028 Subdivision Name: a Phone#: 336-751-8760 Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION - - ir.,p tl AUTHORIZATION NO: U Road Name ' . '� " Zi P **NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie Countv Environmental Health Section prior to issuance of any Building Pennits.This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION t °• h �f`: IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No M` LOT SIZE �PE WATER SUPPLY LI.t� ..t k'-,j ...- DESIGN WASTEWATER FLOW(GPD) 'i�11 NEW SITE REPAIR SITE K"�"' SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. OTHER I I{.^ t 1 ; L) REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT3'S '' l r . Vol U,%) ( f "J **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M.OR 1:00- 1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: J�A C`_,P•A+1� I _ Q -tel - 2� <� AUTHORIZATION NO. OPERATION PERMIT BY: DATE. **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYST I)E CRIBED ABOVE HAS EN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 0=2(Revised) ..� �,. ` / l_l f u) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PO Box 848/210 Hospital Street Mocksville,NC 27028 Phone: (336)751-8760 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) REPLACEMENT REMODELING ❑ RECONNECTION ❑ � A Name: �) l A"� Phone Number: r � �`(�� �U Z� Y� (Home) Mailing Address: �y� ��S ' --`� 1'�� (Work) AbVANc�: , �c- 27 Jy 40 Detailed Directions To Site: Property Address: + Please Fill In The Following Information About The Existing Dwelling: Name System Installed Under: �'t-�t�1►�1 is N�W : Type Of Dwelling: t A Date System Installed(Month/Day/Year): �� '�I^ "'ti Number Of Bedrooms: -",)—_Number Of People: Is The Dwelling Currently Vacant? Yes❑ No� If Yes,For How Long? Any Known Problems?Yes❑ No fT✓ If Yes,Explain: Please Fill In The Following Information About The New Dwelling: Type Of Dwelling: � � N ber Of Bedrooms: Number Of People- Requested By. �" Date Requested:— le equested: `� ( en ture) .�. ' For Environmental Health Office/Use Only!-'- Approved nly!- =Approved ❑ Disapproved ❑ LM1 r Comments: A I��- �L'lr' �,jo:l') DO / d Environmental Health Specialist ` Date -7kl01-j The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee(extended or limited)that the on-site wastewater system will function properly for any given period of time. C;) Payment: Cash❑ Check❑ Money Order❑ # Amount: $ I U 0 Date: Paid By: / Received By: Account #: f off. S Invoice #: - r * DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article I I of G.S.Chapter 130a - Sanitary Sewage Systems Permit Number Name t 1--'tet; 'c' 1 ,�,: r ;c ,ylrl. Date �^ �i J z;: N2 Location Subdivision Name Lot No. Sec. or Block No. Lot Size ° House Mobile Home _�_.- _�' Business -- Speculation No. Bedrooms ' No. Baths —,! No. in Family _ Garbage Disposal YES ❑ NO 0-" Specifications for System: Auto Dish Washer YES ❑ NO Q- r Auto Wash Ma,.hine YES ❑-'INO ❑ Type Water Supply *This permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocation,if site plans or the intended use change. 1 i Improvements permit by *Contact a representative of the Davie County Health Department for final inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number 704-634-5985. Final Installation Diagram: System Installed by, A.� GJ 1 ? ! Certificate of Completion %/2 Date. *The signing of this certificate shall indicate;that the system described above has been installed in compliance with' the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. -s ,r APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department -- - - Environmental Health Section U �1;;,;z;, ;; �" w P. 0. Box 665 Mockoville, NC 27028 JUN 26 6991 1 . Application/Permit Requested By 1 Mailing Address COX lel A49Vd A/C L? Home Phone el qz^ 4 3 ? Business Phone 2. Name on Permit if Different than Above 3. Property Owner if Different than Above 4. Application/Permit For : LC) General Evaluation 0 S/Tank Installation 5. System to Serve: House Mobile Home (] Business Industry u Other 0 Unknown 6. If house, mobile home: Subdivision Sec. Lot# No. of People Dwelling Dimensions 'r 13y �J No. of Bedrooms 2, Basement/Plumbing No. of Bathrooms + Basement/No Plumbing Washing MachineJ Dishwasher 0 Garbage Dlsposai 7. If business, industry, other : Specify type No. of People Served No. of Sinks No. of Commodes No. of Urinals 3 _ No. of Lavatories OL. No. of Water Coolers No. of Showers S. Type of water supply : 0 Public p--V'rivate O Community 9 . Property Dimensions 1 QC'.YP — 10 . Sewage Disposal Contractor 11 . Do you anticipate additions/expansions of the facility this system is intended to serve? G Yes Y'N0 If yes, what type? *NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change . Effective October 1, 1989. This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges incurred from this application . Date Signature Directions to Property : r-OTT-D Y6 Ciof on jn u� I ,4�`pra�4 ,y,c44 l� I z of � )-e-5 c .1-i�/�,'l�- h�m�. a e- on -1 6 ra W n rn b P► 1-e-- k a YYI e ,1�n `C o►�� 0-� i S (a k2 S � DCHD (10-89) DAVIE COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION SITE EVALUATION CONSENT FORM 1. Complete the form below and return to the Davie County Health Department. 2. Carefully follow the procedures as outlined in the enclosed "Information Bulletin." NOTE: THE ABOVE MUST BE COMPLETED BEFORE A SANITARIAN WILL BE ABLE TO BEGIN THE REQUESTED EVALUATION. DETACH HERE AND RETURN TO: Davie County Health Department, Environmental Health Section, P. 0. Box 665, Mocksville, N.C. 27028 Davie County Health Department Environmental Health Section Site Evaluation Consent Form LOCATION OF PROPERTY: DATE RECEIVED 71W5 ��� _ ✓Q C� (office use only) yes no 1. 1 am the owner of the above described property. Qe no 2. 1 am not the owner the above described property, however, I certify that I ��1 have consent from , owner to obtain a owner's name site evaluation by the Davie County Health Department for the purpose of determining the suitability for a ground absorption sewage treatment and disposal system. yes no 3. 1 hereby give consent to the authorized representative of the Davie County Health Departmentto enter upon the above described property and conduct all testing procedures as necessary to determine its suitability for a ground absorption sewage treatment and disposal system. lo 1,2,2jql D, ATE SIGNATURE 4. 1 hereby authorize the Davie County Health Department to release site evaluation results from the above described property to the following: — Owner only — Owners designated representative _Anyone requesting results — Only those listed below c ATE SIGNATU E DCHD(11/84) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation / NAME _ i`� L DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTYLOCATION OF SITE Water Supply: On-Site Well Community Public !/ Evaluation By: Auger Boring i.1/ Pit Cut FACTORS 1 2 3 4 Landscape position Sloe % HORIZON I DEPTH Texture group Consistence Structure MineralogX HORIZON II DEPTH G Texture group C Consistence Structure S Mineralogy - HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATED BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: LEGEND Landscape Position R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope Texture S-Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt SICL-Silty clay loam, SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm Wet NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic Structure SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogy 1:1, 2:1, Mixed Notes Horizon depth - In inches Depth of fill - In inches Restrictive horizon- Thickness and inches from land surface Saprolite - S(suitable), U(unsuitable) Soil wetness - Inches from land surface to free water' or inches from land surface to soil colors with chroma 2 or less Classification - S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 -nCHD(01-901 ■■■■■■■■■■■■■■■■■■■■■.■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■.■■■■■■■■■■■■ ■■■■■■■■��■■■■■■■■■■.■■■■■■■■■.■■■■C■■■■■■■■■■■■■■■■■��■■■■■■■■■■■■■ ■■■■■■■■■�■■■■■■■■■■.■■■■■r.�w��w■■ire■.■.i■.■■■■■■■■u■■■■.■■■■■■■■■■■■ 00 ■■.■■■■■■■\■■■■■■■■■■■■■X111■■■■■■■N■■■■■■■■■■■■■■■■■■[1■■■■■■■■■■■■■ ■■■■■■■■.■■■■■■■■■■■■■■■■w.=Www■■■■■■■_�Cri•■■■■■■■■.■■■■■■t■■■■■■■■ CCC�i■�MENNENEMEMEMMEMOMMUMMEM■CCCCCCNEEMMENNOMEMENNE On MENNOMMONOMEMENN ■■■■■■....■■.■.■■..�:■■■■■.■■■■..�■■■■■■■■N■■■■w■ M■C■■■■C■■■C■■■C ■■■■■■■..■■■■■■■.■■1�■■■■■■■.■■■■ ■■■N■■■..■■■■�■■■.■N■■■..■�■■NO ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■M■■■■■■M ■■I■■■■■■■ ■■M■■■ ■ ■.■■■■■■■■■■■■■■■■■■■■■■■■■■■■t■■■■■■ON=OM==■■■■. ■■■■M.■■■■■■■■■■ ■■■■■■■■■■■■■.■■■■■iii/.■■■■■.■■■■■■■■■■■■■■■11■■ ■■■■M.■■ ■■■■■■M■ ■■■■■■■■■■■■■■■■■■■■■I.■N■■■■■■■■■■.■■■■■■■■■/�■■C ■■■■ ■■C■■■■■■■■C ..............................■..... ......■��.■ ■..............■■E ....... ■....■......I........■■■■■..C.■■■■.■��■.C..■■■■..■■.�■■■.. ...............................�,.■■■■■■■■■■ ■■■■■■■■■■■■■■■■.C■■■ ................................ ....... ........................ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■N■■■.■■■■■■■■■■■■■■■■■■■■■■■■■■■■■